"Maybe he had diarrhea," Wolff speculates. "Or maybe his family was giving [the medika mamba] away. He missed two visits. They gave him a warning. He was supposed to be kicked out if he missed a visit, but the kid probably looks so sick and scrawny they decided to keep him in."

A nurse hired by MFK used to monitor the patients at the Cap-Haïtien-area clinics and make sure they ate their medika mamba. But the nurse resigned, overextended from her other full-time job. Now Wolff must now find a replacement. "Without an enforcer from MFK to make sure they're using medika mamba correctly, the outcomes aren't as good," she explains.

But when the peanut butter is used the right way, "it's a marvel," exclaims Dave Polage, an American who runs a clinic in Terre Blanche, Haiti.

"After we got the product and began using it, we were just amazed by the results," Licia Betor, who runs the Real Hope for Haiti Rescue Center in Cazale, writes in an e-mail. "After living here for fifteen years, you hear lots and lots of stories of products that are good for malnourished children. Many of them are great, but the kids do not like the taste. But the kids loved the medika mamba, and it works so well for those who were so sick."

Still, without more good outcomes, Wolff won't be able to prove to potential donors back in the U.S. that medika mamba is the best way to fight childhood malnutrition in Haiti. Without donations, MFK won't be able to build a new factory. Without the new factory, it won't be able to produce sufficient quantities of medika mamba to sell to big aid organizations such as UNICEF and USAID.

And without turning a profit, the factory will be never be self-sustaining and will, like so many other projects in Haiti, find itself completely dependent on foreign aid.

That is precisely what Wolff does not want.

"Shoot, you need to stay and develop the country," she says. "They don't need to be rescued."

Nothing had prepared Pat Wolff for her first trip to Haiti in 1988. "It felt as though I was at the scene of an accident," she remembers.

She'd traveled to Port-au-Prince with the Haiti Project, a mission group led by Bob Corbett, a retired Webster University professor who had become an expert on Haiti, and his wife, Jane. She and her husband Michael, now a Missouri state Supreme Court justice, and their two sons, then eleven and fourteen, planned to volunteer at Mother Teresa's homes for dying children and dying adults.

As a girl growing up in Minnesota, attending Catholic school, Wolff had been taught that she had an obligation to help the less fortunate. "The underlying message was that you are your brother's keeper, and you should be grateful for what you have," she remembers. "When you have more, you can start making the world a better place. They told us, 'Start doing something, it'll help.' The nuns made it clear: We were not necessarily deserving; we were just lucky."

Wolff had chosen a career in medicine, with the plan of doing missionary work one day. But the demands of a family and a medical practice had gotten in the way. Now she had her chance.

"It was a profoundly awful experience," she recalls. "Most of the people there were dying of something that could have been treated with proper equipment: tuberculosis, malnutrition, infections. All we could do was comfort them as they needlessly died. It was way too little and way too late."

Bob Corbett arranged for Wolff, another doctor and a nurse to travel into the mountains to volunteer at a start-up clinic. They rode horses and donkeys and brought all the medicine they could carry.

"The first day, 300 people showed up," recounts Wolff. "Some of them had walked miles and miles. They had never seen a doctor before. They had heart disease, kidney failure. It couldn't be solved with a Band-Aid. It was eye-opening and upsetting. I went home bedraggled and grief-stricken."

Over the next fifteen years, Wolff returned often to Haiti, mostly to a clinic near Cap-Haïtien. But, she says, "It was like spitting into the ocean. We needed to solve the underlying problem." One in five Haitian children, Wolff learned, is malnourished. One in ten dies before their fifth birthday.

As it happened, one of Wolff's colleagues at Washington University's medical school, Dr. Mark Manary, had been experimenting in the east African nation of Malawi with a radical new treatment for malnutrition. A combination of ground peanuts, powdered milk, sugar, oil and vitamins, it was cheap, easy to produce and high in protein. It was also easy to store, even in a tropical climate. Best of all, patients could be treated at home.

"The only treatment for malnutrition [in developing countries] was in the hospital," Wolff explains. "People would wait in the hospital for months. There was only a 20 or 25 percent recovery rate. And none of the hospitals were free. Mothers would have to stay there with their children, so no one was taking care of the kids left at home."